Name of Individual requesting reasonable accommodation:

Office of Requesting Individual:

1. Reasonable accommodation: (check one)

   _____ Approved

   _____ Denied (If denied, attach copy of the written denial letter/memo - See Section X, page 12, of the Reasonable Accommodation Procedures.)

2. Date reasonable accommodation requested:

   Who received request: _________________________

3. Date reasonable accommodation request referred to decision maker (i.e., supervisor, Office Director, Disability Program Manager, Personnel Management Specialist):

   Name of decision maker: __________________________

4. Date reasonable accommodation approved or denied:
    
5. Date reasonable accommodation provided (if different from date approved):
    
6. If time frames outlined in the Reasonable Accommodation Procedures were not met, please explain why.
    
    
    
7. Job held or desired by individual requesting reasonable accommodation (including occupational series, grade level, and office):
    
    
8. Reasonable accommodation needed for: (check one)

   _____ Application Process

   _____ Performing Job Functions or Accessing the Work Environment

   _____ Accessing a Benefit or Privilege of Employment (e.g., attending a training program or social event)

9. Type(s) of reasonable accommodation requested (e.g., adaptive equipment, staff assistant, removal of architectural barrier):
    
    
    
    
10. Type(s) of reasonable accommodation provided (if different from what was requested):
     
     
     
     
11. Was medical information required to process this request? If yes, explain why.
     
     
     
     
12. Sources of technical assistance, if any, consulted in trying to identify possible reasonable accommodations (e.g., Job Accommodation Network, disability organization, Disability Program Manager):
     
     
     
     
13. Comments:
    
     
     
     
     
     
     
     
     

Submitted by: ___________________ Phone: ________________

Attach copies of all documents obtained or developed in processing this request.